Preventing Wrong-Site Surgery Through Implementation of Evidenced-Based Best Practices Robert Yonash, RN, CPPS Pennsylvania Patient Safety Authority Patient Safety Liaison, Southwest Region
Objectives Recognize that wrong-site surgery events continue to be a threat to patient safety Describe how the Patient Safety Authority identifies wrong-site surgery events Identify the factors that contribute to wrong-site surgery events Describe some evidence-based best practices that prevent wrong-site surgery Explain how implementation and compliance of best practices can eliminate wrong-site surgery events 2
A Threat to Patient Safety Joint Commission - Sentinel Event National Quality Forum - Serious Preventable Events Centers for Medicare & Medicaid Services -Non- Coverage Determination World Health Organization Patient Safety Alliance - Patient Safety Goal 3
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Note: Data reflects events reported from June 2004 through December2016 6
Frequency of WSS Events in ASFs About 30% of all WSS events reported to the Authority between July 2005 through June 2016 were reported by Pennsylvania ambulatory surgical facilities. About 17 events reported annually 1.4 events reported monthly 7
Number of WSS Events Number of ASF WSS Events Reported through PA-PSRS by Academic Year Academic Year 8
Percentage Percentage of Overall WSS Events Reported by ASFs Academic Year 9
WSS Events Reported 2010-2016 59% - Wrong-Side Procedures Blocks by anesthesiologists and surgeons Pain management injections Eye procedures 32% - Wrong-Site Procedures Excisions/biopsies Pain injections Hand procedures (i.e., incisions) Spinal level procedures 9% - Wrong Procedures Tonsillectomy Hand procedures (e.g., Carpal tunnel release) 10
What is Wrong- Site Surgery? Wrong body part Wrong side Wrong patient Wrong procedure 11
Definition Procedure begins when: tissue punctured incision made instrument inserted into a tissue cavity or organ Wrong-site surgery also occurs if a procedure begins at the wrong site and is then corrected 12
Definition Includes Procedures in the operating room area Area where preoperative anesthetic blocks given Area where postoperative pain management anesthetic blocks given 13
Definition Excludes Insertion of incorrect implants (e.g., left/right) it must be the correct type of implant Incorrect interpretation of anatomical structures when verification by radiography is not tenable 14
Common Contributing Factors Inaccurate information Schedule, consent, history and physical, diagnostic report(s)/image(s) No verification of documents or site marking Local anesthesia given without conducting a time-out Patient positioning conceals surgical mark Proper time-out not completed 15
Causes of Wrong-Site Surgery Acting on the basis of misinformation. t What prevents it? Having a misperception of the patient s situation. What prevents it? 16
Implementing Best Practices Preoperative verification and reconciliation Site marking Time-out Intraoperative verification for ureteral stents, ribs and vertebrae 17
Preoperative Verification Verification of all relevant documents (schedule, history and physical, and consent) Include the site/side on the schedule Require two identifiers in the active voice Obtain separate verification by nurse and surgeon Ensure all documents are available in the OR 18
OR schedule lists operation as right knee arthroscopy. OR consent and H&P [history and physical] state left knee arthroscopy. Patient identified left knee as site of surgery. The left knee was marked. Timeout documentation indicated left knee as site of surgery. Arthroscopy performed on the right knee. Pa Patient Saf Advis 2015 Mar;12(1):19-27. 19
Incorrect paperwork [identified] in pre-op during the verification process. Preop physician orders state right shoulder surgery. Patient is scheduled to have right knee meniscectomy. Call placed to preadmission testing to have paperwork corrected prior to surgery. 20
Represents the patient s voice Agrees with patient and all information schedule, consent, history & physical Is a standardized site marked with the provider s initials Is referenced before anesthesia block Is visible in prepped and draped field Is confirmed by intraoperative imaging Vertebrae, ribs, or ureters Site Marking 21
The patient consented to the removal of a left heel bone spur and a right bunionectomy. He had identical pathologies in both feet. The patient was identified, the time-out was done, and the surgical sites were marked appropriately with the patient supine. The patient was turned prone, removing the site markings from the visual field, and the procedures were performed in the reverse. Pa Patient Saf Advis 2015 Mar;12(1):19-27. 22
Patient consented for repair of right inguinal hernia. The Universal Protocol was completed for the right side. The time-out was completed for the right.... The patient was marked preoperatively by the surgeon, but the marking was not visible after draping was completed. The surgery proceeded as usual until the surgeon asked for a left-side mesh. At that time, it was noted they were doing a left inguinal hernia. 23
Confirmation Bias Patient was placed in pre-op holding area for placement of right femoral nerve block before right ankle surgery. Equipment was brought into the holding area and happened to be placed in an orientation consistent with performing a left femoral nerve block (ultrasound on patient s right side). Anesthesiologist was standing on patient s left side when time-out was performed with CRNA. CRNA left to obtain sedation while anesthesiologist drew up medications necessary for block on counter behind patient. After drawing up drugs, anesthesiologist proceeded to prep and drape the wrong side. Block was performed without incident. Following completion of block, the patient s covers (which were covering from thigh down) were pulled back to assess adequacy of block when surgical signature was noted on the contralateral ankle. Pa Patient Saf Advis 2015 Mar;12(1):41-4. 24
Time-out Stop all activity Do a separate time-out for regional and local anesthetics Do a time-out after patient is prepped and draped Demonstrate site mark during timeout Engage and empower OR team to speak-up Use intraoperative imaging 25
Separate Time Out For Anesthesia The anesthesia provider identified the patient, introduced herself, did the H&P [history and physical], then went over the anesthetic plan with the patient: a block with IV [intravenous] sedation. The provider obtained the patient s consent and asked what side was to have surgery. The patient said and pointed to his right shoulder. The provider then prepared to place the IV.... The provider asked again what side was having surgery. The patient said right. The provider then [went somewhere] to gather the ultrasound and the items needed to place the block. When she returned, the patient s left shoulder was out of the gown and his right shoulder was in the gown. The provider proceeded to prep the left shoulder while discussing how the block worked with the patient s companion. At that point, the provider s supervisor arrived. The provider put her gloves on and proceeded to block the wrong shoulder. 26
A [patient] was admitted for right knee arthroscopy. Patient properly identified; site properly marked; and patient brought to OR. Physician elevated the left leg for the procedure. Nurse prepped and draped the knee. During the timeout, no one recognized that the wrong leg had been prepared. The procedure was performed on the incorrect leg. Pa Patient Saf Advis 2015 Mar;12(1):19-27. 27
Scheduled for release of trigger finger; consent indicated same; site marked by surgeon;... during prep, site mark washed off with alcohol; MD proceeded to do a carpal tunnel, then realized he was to do trigger finger; MD told staff he was thinking about a patient he had done previous day; MD said the time-out was done. 28
Surgery was scheduled and consent obtained for repair of a right hip fracture. The patient marked the site, and team verification pause occurred. However, the patient was positioned with the left hip draped and prepped, and the surgery proceeded. After the incision, the error was realized. The incision was sutured and the patient repositioned, and surgery resumed on the right hip. 29
Intraoperative Verification North American Spine Society Recommendations: Identify spine or rib with immobile marker Verify location by imaging studies Ensure official real-time reading by surgeon and radiologist 30
An intraoperative fluoroscopy was used to localize the incision over C5-6. Fluoroscopy revealed that needle was at C4-5, so dissection was carried further distally to the presumed C5-6 level. The procedure was completed. However, a followup x-ray revealed that the site was C6-7. 31
Nothing is Absolute Asking the patient or surgeon may not always prevent a wrong-side error Marking the patient may not always prevent a wrong-side error Doing a time-out may not always prevent a wrongside error 32
Nothing is Absolute The surgeon marked the patient s surgical site in the preoperative area immediately after checking the patient s history and physical, the operative consent, and confirming with the patient. The patient then called the nurse over to the bedside and stated she marked the wrong side. Pa Patient Saf Advis 2012 Sep;9(3):111-12. 33
Collaborations Southeastern Pennsylvania (2008) 30 facilities participated 73% reduction in reported WSS events Elsewhere in Pennsylvania (2010-2012) 19 facilities participated No WSS events in any operating room for one year PA-Hospital Engagement Network 2011-2014 26 hospital and 2 ambulatory surgical centers participated PA Society of Anesthesiologists Ongoing 34
Collaboration Outcomes http://patientsafetyauthority.org/advisories/advisorylibrary/2012/mar;9(1)/pages/28.aspx 35
Evidence-Based Principles http://www.patientsafetyauthority.org/educationaltools/patientsafetytools/pwss/pages/principles.aspx 36
Evidence-Based Principles Pa Patient Saf Advis 2010 Dec;7(4):151-4. 37
Evidence-Based Principles Pa Patient Saf Advis 2010 Dec;7(4):151-4. 38
Evidence-Based Principles Pa Patient Saf Advis 2010 Dec;7(4):151-4. 39
Evidence-Based Principles Pa Patient Saf Advis 2010 Dec;7(4):151-4. 40
Additional Suggested Orthopedic Practices To minimize the risk of a wrong-site anesthesia block, mark the operative site before the anesthesiologist does the block. Make the site marking as close to the incision as possible and reference it during the positioning of the extremity, the application of any tourniquet, and the prepping and draping of the operative site, as well as during the final time-out just prior to the incision. This appears to be especially important for hand procedures, where the entire hand is in the operative field. Do a separate time-out for any injection not done in continuity with the incision, such as a preoperative intra-articular injection of the knee. Have the surgeon state the procedure and site, rather than agree to the stated procedure and site, to minimize the risks of automated behavior. When doing separate procedures on the same patient, do separate timeouts immediately before each procedure instead of a single time-out referencing the multiple procedures and sites. Pa Patient Saf Advis 2015 Mar;12(1):41-4. 41
Preventing Wrong-Site Surgery All critical documents agree before going into the operating room Site marking is accurate and always visible Surgeon is engaged in the time-out 42
The Goal Getting to Zero! 43
Questions? 44
References Clarke, JR. Quarterly Update on Preventing Wrong-Site Surgery Pa Patient Saf Advis 2010 Dec;7(4):151-4. Clarke, JR. Quarterly Update on Preventing Wrong-Site Surgery Pa Patient Saf Advis 2012 Mar;9(1):28-34. Clarke, JR. Quarterly Update to Preventing Wrong Site Surgery. Pa Patient Saf Advis 2012 Sep;9(3):111-112. Clarke, JR. What Keeps Facilities from Implementing Best Practices to Prevent Wrong-Site Surgery? Pa Patient Saf Advis 2012 Nov 20;9(Suppl1):1-15. 45
References Clarke, JR. Quarterly Update on Wrong-Site Surgery: Facilities with Barriers to Best Practices May Experience More Wrong- Site Surgeries Pa Patient Saf Advis 2012 Dec;9(4):145-9. Clarke, JR. Quarterly Update: What Body Parts and Procedures Are Associated with Wrong-Site Surgery? Pa Patient Saf Advis 2013 Mar;10(1):34-40. Clarke, JR. Quarterly Update on Wrong-Site Surgery: Trying to Hold the Gains Pa Patient Saf Advis 2013 Jun;10(2):76-81 46
References Clarke, JR. Quarterly Update on Wrong-Site Surgery: How to Do an Effective Time-Out in the Dark Pa Patient Saf Advis 2014 Jun;11(2):88-92 Clarke, JR. Quarterly Update on Wrong-Site Surgery: Do You Really Want to Wake the Patient Up and Start Over? Pa Patient Saf Advis 2015 Mar;12(1):41-4. Clarke, JR. Wrong-Site Orthopedic Operations on the Extremities: The Pennsylvania Experience Pa Patient Saf Advis 2015 Mar;12(1):19-27. You can reference the Preventing Wrong Site Surgery Educational Tools at http://patientsafetyauthority.org/educationaltools/patientsafetyto ols/pwss/pages/home.aspx 47
Thank You! www.patientsafetyauthority.org 48